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Zeigler Z, Acevedo AM. Re-evaluating the Need for Routine Maximal Aerobic Capacity Testing within Fighter Pilots. Aerosp Med Hum Perform 2024; 95:273-277. [PMID: 38715261 DOI: 10.3357/amhp.6409.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
INTRODUCTION: There is a current belief in aviation suggesting that aerobic training may reduce G-tolerance due to potential negative impacts on arterial pressure response. Studies indicate that increasing maximal aerobic capacity (V˙o₂ max) through aerobic training does not hinder G-tolerance. Moreover, sustained centrifuge training programs revealed no instances where excessive aerobic exercise compromised a trainee's ability to complete target profiles. The purpose of this review article is to examine the current research in the hope of establishing the need for routine V˙o₂-max testing in air force pilot protocols.METHODS: A systematic search of electronic databases including Google Scholar, PubMed, the Aerospace Medical Association, and Military Medicine was conducted. Keywords related to "human performance," "Air Force fighter pilots," "aerobic function," and "maximal aerobic capacity" were used in various combinations. Articles addressing exercise physiology, G-tolerance, physical training, and fighter pilot maneuvers related to human performance were considered. No primary data collection involving human subjects was conducted; therefore, ethical approval was not required.RESULTS: The V˙o₂-max test provides essential information regarding a pilot's ability to handle increased Gz-load. It assists in predicting G-induced loss of consciousness by assessing anti-G straining maneuver performance and heart rate variables during increased G-load.DISCUSSION: V˙o₂-max testing guides tailored exercise plans, optimizes cardiovascular health, and disproves the notion that aerobic training hampers G-tolerance. Its inclusion in air force protocols could boost readiness, reduce health risks, and refine training for fighter pilots' safety and performance. This evidence-backed approach supports integrating V˙o₂-max testing for insights into fitness, risks, and tailored exercise.Zeigler Z, Acevedo AM. Re-evaluating the need for routine maximal aerobic capacity testing within fighter pilots. Aerosp Med Hum Perform. 2024; 95(5):273-277.
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Bourque JM. Cardiac PET Perfusion Imaging: AURORA Lights the Way to a New Era. J Am Coll Cardiol 2023; 82:1611-1613. [PMID: 37821171 DOI: 10.1016/j.jacc.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Jamieson M Bourque
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA.
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Oliveira GMMD, Almeida MCCD, Rassi DDC, Bragança ÉOV, Moura LZ, Arrais M, Campos MDSB, Lemke VG, Avila WS, Lucena AJGD, Almeida ALCD, Brandão AA, Ferreira ADDA, Biolo A, Macedo AVS, Falcão BDAA, Polanczyk CA, Lantieri CJB, Marques-Santos C, Freire CMV, Pellegrini D, Alexandre ERG, Braga FGM, Oliveira FMFD, Cintra FD, Costa IBSDS, Silva JSN, Carreira LTF, Magalhães LBNC, Matos LDNJD, Assad MHV, Barbosa MM, Silva MGD, Rivera MAM, Izar MCDO, Costa MENC, Paiva MSMDO, Castro MLD, Uellendahl M, Oliveira Junior MTD, Souza OFD, Costa RAD, Coutinho RQ, Silva SCTFD, Martins SM, Brandão SCS, Buglia S, Barbosa TMJDU, Nascimento TAD, Vieira T, Campagnucci VP, Chagas ACP. Position Statement on Ischemic Heart Disease - Women-Centered Health Care - 2023. Arq Bras Cardiol 2023; 120:e20230303. [PMID: 37556656 PMCID: PMC10382148 DOI: 10.36660/abc.20230303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Andreia Biolo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | | | | | | | - Celi Marques-Santos
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Hospital São Lucas Rede D'Or São Luis, Aracaju, SE - Brasil
| | | | - Denise Pellegrini
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | - Fabiana Goulart Marcondes Braga
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Lara Terra F Carreira
- Cardiologia Nuclear de Curitiba, Curitiba, PR - Brasil
- Hospital Pilar, Curitiba, PR - Brasil
| | | | | | | | | | | | | | | | | | | | | | - Marly Uellendahl
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
| | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | - Ricardo Quental Coutinho
- Faculdade de Ciências Médicas da Universidade de Pernambuco (UPE), Recife, PE - Brasil
- Hospital Universitário Osvaldo Cruz da Universidade de Pernambuco (UPE), Recife, PE - Brasil
| | | | - Sílvia Marinho Martins
- Pronto Socorro Cardiológico de Pernambuco da Universidade de Pernambuco (PROCAPE/UPE), Recife, PE - Brasil
| | | | - Susimeire Buglia
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | - Thais Vieira
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Rede D'Or, Aracaju, SE - Brasil
- Hospital Universitário da Universidade Federal de Sergipe (UFS), Aracaju, SE - Brasil
| | | | - Antonio Carlos Palandri Chagas
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Centro Universitário Faculdade de Medicina ABC, Santo André, SP - Brasil
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4
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Eklund Gustafsson C, Ekström M, Ugander M, Brudin L, Carlén A, Hedman K, Lindow T. Prognostic value of peak work rate indexed by left ventricular diameter. Sci Rep 2023; 13:8806. [PMID: 37258692 DOI: 10.1038/s41598-023-35976-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 05/26/2023] [Indexed: 06/02/2023] Open
Abstract
Left ventricular diameter (LVEDD) increases with systematic endurance training but also in various cardiac diseases. High exercise capacity associates with favorable outcomes. We hypothesized that peak work rate (Wpeak) indexed to LVEDD would carry prognostic information and aimed to evaluate the association between Wpeak/LVEDDrest and cardiovascular mortality. Wpeak/LVEDDrest (W/mm) was calculated in patients with an echocardiographic examination within 3 months of a maximal cycle ergometer exercise test. Low Wpeak/LVEDDrest was defined as a value below the sex- and age-specific 5th percentile among lower-risk subjects. The association with cardiovascular mortality was evaluated using Cox regression. In total, 3083 patients were included (8.0 [5.4-11.1] years of follow-up, 249 (8%) cardiovascular deaths). Wpeak/LVEDDrest (W/mm) was associated with cardiovascular mortality (adjusted hazard ratio (HR) 0.28 [0.22-0.36]), similar to Wpeak in % of predicted, with identical prognostic strength when adjusted for age and sex (C-statistics 0.87 for both). A combination of low Wpeak/LVEDDrest and low Wpeak was associated with a particularly poor prognosis (adjusted HR 6.4 [4.0-10.3]). Wpeak/LVEDDrest was associated with cardiovascular mortality but did not provide incremental prognostic value to Wpeak alone. The combination of a low Wpeak/LVEDDrest and low Wpeak was associated with a particularly poor prognosis.
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Affiliation(s)
- Charlotte Eklund Gustafsson
- Department of Clinical Physiology, Research and Development, Växjö Central Hospital, Region Kronoberg, Växjö, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden
| | - Martin Ugander
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, Australia
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Carlén
- Department of Clinical Physiology in Linköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Thomas Lindow
- Department of Clinical Physiology, Research and Development, Växjö Central Hospital, Region Kronoberg, Växjö, Sweden.
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
- Clinical Physiology, Clinical Sciences, Lund University, 221 00, Lund, Sweden.
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5
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Hage FG, Einstein AJ, Ananthasubramaniam K, Bourque JM, Case J, DePuey EG, Hendel RC, Henzlova MJ, Shah NR, Abbott BG, Al Jaroudi W, Better N, Doukky R, Duvall WL, Malhotra S, Pagnanelli R, Peix A, Reyes E, Saeed IM, Sanghani RM, Slomka PJ, Thompson RC, Veeranna V, Williams KA, Winchester DE. Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement. J Nucl Cardiol 2023; 30:864-907. [PMID: 36607538 DOI: 10.1007/s12350-022-03162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Fadi G Hage
- Section of Cardiology, Birmingham VA Medical Center, Birmingham, AL, USA.
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 446 GSB, 520 19Th Street South, Birmingham, AL, 35294, USA.
| | - Andrew J Einstein
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine and Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Jamieson M Bourque
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, VA, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - James Case
- Cardiovascular Imaging Technologies, Kansas City, MO, USA
| | - E Gordon DePuey
- Mount Sinai Morningside Hospital, New York, NY, USA
- Bay Ridge Medical Imaging, Brooklyn, NY, USA
| | - Robert C Hendel
- Department of Medicine, Division of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Nishant R Shah
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Brian G Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Wael Al Jaroudi
- Division of Cardiovascular Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nathan Better
- Department of Nuclear Medicine and Cardiology, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Rami Doukky
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | | | - Amalia Peix
- Nuclear Medicine Department, Institute of Cardiology and Cardiovascular Surgery, La Habana, Cuba
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ibrahim M Saeed
- Virginia Heart, Falls Church, VA, USA
- INOVA Heart and Vascular Institute, Falls Church, VA, USA
- University of Missouri, Kansas City, MO, USA
| | - Rupa M Sanghani
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vikas Veeranna
- Division of Cardiology, Department of Medicine, New England Heart and Vascular Institute, Manchester, NH, USA
| | - Kim A Williams
- Department of Medicine, University of Louisville Department of Medicine, Louisville, KY, USA
| | - David E Winchester
- Malcom Randall VA Medical Center, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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6
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Ukashi O, Pflantzer B, Barash Y, Klang E, Segev S, Ozeri DJ, Veisman I, Lahat A, Laish I, Kopylov U, Oppenheim A. Cardiovascular Risk Factors and Physical Fitness Among Subjects with Asymptomatic Colonic Diverticulosis. Dig Dis Sci 2023; 68:902-912. [PMID: 35695973 DOI: 10.1007/s10620-022-07572-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/18/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The association between diverticular disease and atherosclerotic cardiovascular disease (ASCVD) has been demonstrated previously, mainly in symptomatic subjects. AIMS To evaluate 10 years cardiovascular risk, exercise performance and association to ASCVD among subjects with asymptomatic diverticulosis. METHODS A retrospective cross-sectional cohort of self-referred participants in a medical screening program, who underwent a screening colonoscopy. Demographics, clinical and laboratory variables, ASCVD score, and metabolic equivalents (METs) during treadmill stress test were compared between subjects with and without diverticulosis as diagnosed on screening colonoscopy. RESULTS 4586 participants underwent screening colonoscopy; 799 (17.4%) had diverticulosis. Among 50-69 yo participants, diverticulosis subjects had a higher ASCVD score compared to non-diverticulosis subjects. Exercise performance was comparable between the groups, across all age groups. Using logistic regression analysis, advanced age group (50-59 yo Adjusted odds ratio (AOR) [95% confidence interval (CI)] 2.57 (1.52-4.34), p < 0.001; 60-69 yo, AOR 2.87 (2.09-3.95), p < 0.001; ≥ 70 yo AOR 4.81 (3.23-7.15), p < 0.001; compared to < 50 yo age group), smoking [AOR 1.27 (1.05-1.55), p = 0.016], HTN [AOR 1.27 (1.03-1.56), p = 0.022], obesity [AOR 1.36 (1.06-1.74), p = 0.014] and male sex [AOR 1.29 (1.02-1.64), p = 0.036] were associated with diverticular detection during screening colonoscopy. Among males, achieving METs score ≥ 10 was inversely associated with diverticular detection during screening colonoscopy [AOR 0.64 (0.43-0.95), p = 0.027]. CONCLUSIONS Ten years probability for ASCVD estimated by the ASCVD score is higher among subjects with asymptomatic diverticulosis compared to subjects without diverticulosis. Improved exercise performance is demonstrated for the first time to correlate with decreased probability for diverticular disease in screening colonoscopy.
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Affiliation(s)
- Offir Ukashi
- Department of Gastroenterology, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel.
- Department of Internal Medicine A, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Barak Pflantzer
- Department of Internal Medicine A, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yiftach Barash
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel
- DeepVision Lab, Sheba Medical Center, Ramat-Gan, Israel
| | - Eyal Klang
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel
- DeepVision Lab, Sheba Medical Center, Ramat-Gan, Israel
| | - Shlomo Segev
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Institute of Medical Screening, Sheba Medical Center, Ramat-Gan, Israel
| | - David J Ozeri
- Department of Internal Medicine A, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Rheumatology, Sheba Medical Center, Ramat-Gan, Israel
| | - Ido Veisman
- Department of Gastroenterology, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ido Laish
- Department of Gastroenterology, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amit Oppenheim
- Department of Internal Medicine A, Sheba Medical Center, Ha'ela 1, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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7
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Lin WC, Huang MS, Liu PY. Underestimating the Risk of an Inconclusive Result in Exercise Treadmill Tests for Patients With Suspected Ischemic Heart Disease. Circ J 2023; 87:368-375. [PMID: 36155942 DOI: 10.1253/circj.cj-22-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The exercise stress test is a widely used noninvasive test for diagnosing ischemic heart disease. Patients with a "positive" result have a higher risk than those with a "negative" result. However, the outcomes of patients with an "inconclusive" result remain uncertain.Methods and Results: We retrospectively collected the data of patients who underwent an ECG-based treadmill stress test between August 2009 and March 2020. Propensity score matching (PSM) was performed to adjust for confounders. Clinical outcomes were compared in terms of all-cause death and cardiovascular (CV) death. Subgroup analysis evaluated treatment interactions, including medication and examinations. In total, 25,475 patients were recruited, and after exclusion and PSM, 4,847 (1,621 with a positive result, 1,606 with a negative result, and 1,621 with an inconclusive result) remained. Compared with the negative group, the inconclusive group, but not the positive group, had a significantly worse outcome in terms of all-cause death (hazard ratio [HR]: 1.834, 95% confidence interval [CI]: 1.34-2.511 and HR: 1.327, 95% CI: 0.949-1.857, respectively); however, CV death was not significantly different in the inconclusive and positive groups (HR: 1.728, 95% CI: 0.413-7.232 and HR: 2.067, 95% CI: 0.517-8.264, respectively). CONCLUSIONS Clinicians must not underestimate the potential for worse outcomes in patients with an inconclusive stress test result.
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Affiliation(s)
- Wei-Chen Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University.,Department of Medicine, College of Medicine, National Cheng Kung University
| | - Mu-Shiang Huang
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University.,Department of Statistics, College of Management, National Cheng Kung University
| | - Ping-Yen Liu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University.,Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
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8
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Rozanski A, Miller RJH, Han D, Gransar H, Slomka P, Dey D, Hayes SB, Friedman J, Thomson LB, Berman DS. The prevalence and predictors of inducible myocardial ischemia among patients referred for radionuclide stress testing. J Nucl Cardiol 2022; 29:2839-2849. [PMID: 34608604 DOI: 10.1007/s12350-021-02797-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/30/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND The frequency of inducible myocardial ischemia has declined in contemporary stress test cohorts, suggesting a need to re-evaluate its optimal use. To-date, however, a comprehensive analysis of the most potent predictors of myocardial ischemia among cardiac stress test patients has not been conducted. METHODS We assessed 27,615 patients referred for stress-rest SPECT myocardial perfusion imaging between January 1, 2004 and December 31, 2017. Chi-square analysis was used to ascertain the most potent predictors of ischemia. RESULTS Among our cohort, CAD status (presence/absence of known CAD), rest left ventricular ejection fraction (LVEF), and typical angina were the most potent predictors of ischemia. The frequency of ischemia was only 6.6% among patients with an LVEF > 55% but 38.1% for patients with LVEF < 45% (P < 0.001). The frequency of myocardial ischemia was fourfold higher among patients with known CAD vs no known CAD (28.0% vs 6.5%, P < 0.001) and approximately threefold higher among patients with typical angina vs patients with atypical symptoms (P < 0.001). CONCLUSIONS The frequency of myocardial ischemia varies markedly according to the common clinical parameters and is particularly high among patients with known CAD, low LVEF, and typical angina. These observations may be used to develop more cost-effective strategies for referring patients for cardiac stress testing.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean B Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise B Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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9
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Barbieri A, Bursi F, Santangelo G, Mantovani F. Exercise Stress Echocardiography for Stable Coronary Artery Disease: Succumbed to the Modern Conceptual Revolution or Still Alive and Kicking? Rev Cardiovasc Med 2022; 23:275. [PMID: 39076615 PMCID: PMC11266956 DOI: 10.31083/j.rcm2308275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 07/31/2024] Open
Abstract
The modern conceptual revolution in managing patients with stable coronary artery disease (CAD), based on improvement in preventive and pharmacological therapy, advocates coronary artery revascularization only for smaller group of patients with refractory angina, poor left ventricular systolic function, or high-risk coronary anatomy. Therefore, our conventional wisdom about stress testing must be questioned within this new and revolutionary paradigm. Exercise stress echocardiography (ESE) is still a well-known technique for assessing known or suspected stable CAD, it is safe, accessible, and well-tolerated, and there is an widespread evidence base. ESE has been remarkably resilient throughout years of innovation in noninvasive cardiology. Its value is not to be determined over the short portion of diagnostic accuracy but mainly through its prognostic value evident in a wide range of patient subsets. It is coming very close to the modern profile of a leading test that should include, in addition to an essential accettable diagnostic and prognostic accuracy, qualities of low cost, no radiation exposure, and minor environmental traces. In this review, we will discuss advantages, diagnostic accuracy, prognostic value in general and special populations, cost-effectiveness, and changes in referral patterns of ESE in the modern era.
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Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Francesca Bursi
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, 20122 Milan, Italy
- Department of Health Sciences, University of Milan, 20122 Milan, Italy
| | - Gloria Santangelo
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, 20122 Milan, Italy
| | - Francesca Mantovani
- Division of Cardiology, Azienda USL–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy
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10
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Bays HE, Kulkarni A, German C, Satish P, Iluyomade A, Dudum R, Thakkar A, Rifai MA, Mehta A, Thobani A, Al-Saiegh Y, Nelson AJ, Sheth S, Toth PP. Ten things to know about ten cardiovascular disease risk factors - 2022. Am J Prev Cardiol 2022; 10:100342. [PMID: 35517870 PMCID: PMC9061634 DOI: 10.1016/j.ajpc.2022.100342] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/19/2022] [Accepted: 04/01/2022] [Indexed: 12/12/2022] Open
Abstract
The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.
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Affiliation(s)
- Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Clinical Associate Professor, University of Louisville School of Medicine, 3288 Illinois Avenue, Louisville KY 40213
| | - Anandita Kulkarni
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701
| | - Charles German
- University of Chicago, Section of Cardiology, 5841 South Maryland Ave, MC 6080, Chicago, IL 60637
| | - Priyanka Satish
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA 77030
| | - Adedapo Iluyomade
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL 33176
| | - Ramzi Dudum
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA
| | - Aarti Thakkar
- Osler Medicine Program, Johns Hopkins Hospital, Baltimore MD
| | | | - Anurag Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Aneesha Thobani
- Emory University School of Medicine | Department of Cardiology, 101 Woodruff Circle, WMB 2125, Atlanta, GA 30322
| | - Yousif Al-Saiegh
- Lankenau Medical Center – Mainline Health, Department of Cardiovascular Disease, 100 E Lancaster Ave, Wynnewood, PA 19096
| | - Adam J Nelson
- Center for Cardiovascular Disease Prevention, Cardiovascular Division, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX 75093
| | - Samip Sheth
- Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, DC 20007
| | - Peter P. Toth
- CGH Medical Cener, Sterling, IL 61081
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Rodriguez Lozano P, Bourque JM. Beyond traditional cardiovascular risk factors: Could frailty and other morbidities explain the worse prognosis in patients undergoing pharmacologic stress? J Nucl Cardiol 2022; 29:853-856. [PMID: 33241477 PMCID: PMC8144235 DOI: 10.1007/s12350-020-02441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Patricia Rodriguez Lozano
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamieson M Bourque
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA.
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA.
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12
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Ananthasubramaniam G, Ananthasubramaniam K. Stress Electrocardiography Testing in Coronary Artery Disease: Is It Time for Its Swan Song or To Redefine Its Role in the Modern Era ? Indian Heart J 2022; 74:81-85. [PMID: 35167825 PMCID: PMC9039687 DOI: 10.1016/j.ihj.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/27/2022] Open
Abstract
Stress electrocardiography (sECG) or treadmill stress testing is a well validated noninvasive diagnostic modality available to clinicians at low cost yet providing valuable functional data for coronary artery disease (CAD) diagnostic and prognostic evaluation. With the advances in cardiac imaging in both functional and anatomic fronts and the existing limitations of sECG testing, this modality appears less favored worldwide as reflected in some recent guideline updates. We review the past present and future of sECG to provide a viewpoint on where it stands in CAD evaluation and if it will remain relevant as a diagnostic modality or be retired going forward. We also provide our perspectives on how sECG can co-exist with other modalities such as calcium scoring and discuss the role of such testing in the Indian population.
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13
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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14
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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15
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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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16
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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17
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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18
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Performance and Interpretation of Office Exercise Stress Testing. Prim Care 2021; 48:627-643. [PMID: 34752274 DOI: 10.1016/j.pop.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In an era where cardiovascular disease continues to increase in prevalence, chest pain is a commonly encountered complaint in the outpatient setting. Clinicians are often tasked with the challenge of selecting the most appropriate screening tool in the evaluation of a patient with suspected coronary artery disease. With proper consideration of indications and contraindications, exercise electrocardiogram (ECG) stress testing is an accessible, cost-conscious, and validated outpatient diagnostic modality for predicting coronary artery disease.
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19
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Peclat TR, de Souza ACDAH, Souza VF, Nakamoto AMK, Neves FM, Silva ICR, Lima RSL. The additional prognostic value of myocardial perfusion SPECT in patients with known coronary artery disease with high exercise capacity. J Nucl Cardiol 2021; 28:2056-2066. [PMID: 31792916 DOI: 10.1007/s12350-019-01960-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The prognostic value of myocardial perfusion imaging (MPI) in patients with known coronary artery disease (CAD) and high exercise capacity is still unknown. We sought to determine the MPI additional prognostic value over electrocardiography (ECG) stress testing alone in patients with known CAD who achieved ≥ 10 metabolic equivalents (METs). METHODS AND RESULTS We evaluated 926 patients with known CAD referred for MPI with exercise stress. Patients were followed for a mean of 32.4 ± 9.7 months for the occurrence of all-cause death or nonfatal myocardial infarction (MI). Those achieving ≥ 10 METs were younger, predominantly male, and had lower prevalence of cardiovascular risk factors. Patients reaching ≥ 10 METs had a lower annualized rate of hard events compared to their counterparts achieving < 10 METs (1.13%/year vs 3.95%/year, P < .001). Patients who achieved ≥ 10 METs with abnormal scans had a higher rate of hard events compared to those with normal scans (3.37%/year vs 0.57%/year, P = .023). Cardiac workload < 10 METs and an abnormal MPI scan were independent predictors of hard events. CONCLUSIONS MPI is able to stratify patients with known CAD achieving ≥ 10 METs for the occurrence of all-cause death and nonfatal MI, with incremental prognostic value over ECG stress test alone.
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Affiliation(s)
- Thais R Peclat
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Ana Carolina do A H de Souza
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Victor F Souza
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aline M K Nakamoto
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Felipe M Neves
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Izabella C R Silva
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ronaldo S L Lima
- Cardiology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Fonte Imagem, Rio de Janeiro, Brazil
- Clínica de Diagnóstico por Imagem, Rio de Janeiro, Brazil
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20
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Petretta M. Rise and fall, and provisional rebirth of exercise stress testing at the dawn of the third millennium. J Nucl Cardiol 2021; 28:2067-2071. [PMID: 31792917 DOI: 10.1007/s12350-019-01967-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.
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21
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Whitman M, Jenkins C. Rate pressure product, age predicted maximum heart rate or heart rate reserve. Which one better predicts cardiovascular events following exercise stress echocardiography? AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:450-457. [PMID: 34548942 PMCID: PMC8449196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Age-predicted maximum heart rate (APMHR) has been demonstrated to be a poor predictor of future cardiovascular (CV) events and is yet to be validated as a termination point during exercise testing. In contrast, maximum rate pressure product (MRPP) is recognized as a strong predictor of CV outcome with superior CV event prediction over APMHR. Heart rate reserve (HRR) has been shown to be a powerful predictor of CV mortality during exercise testing, however thus far, this is not confirmed for non-fatal CV events. The aim of this study was to compare APMHR, MRPP and HRR as predictors of CV events following otherwise negative exercise treadmill testing. METHODS After exclusions, 1080 patients being investigated for coronary artery disease performed an exercise stress echocardiogram (ESE) to volitional fatigue on a motorised treadmill. Blood pressure was measured manually, and ultrasound images performed as per current American Society of Echocardiography guidelines. Rate pressure product and HRR were calculated throughout the test and maximum values were identified. Patients were followed for 5.3±2.6 mean years. RESULTS From receiver operating characteristic analysis, cut points were established for APMHR (94.6%) (AUC 0.687), MRPP (25085) (AUC 0.729) and HRR% (95.9) (AUC 0.688). MRPP outperformed both APMHR and HRR% for the prediction of future CV events. Furthermore, on Cox proportional hazard analysis MRPP was the strongest uni- and multivariate predictor (p<0.0001) with APMHR and HRR% failing to reach any statistical significance. CONCLUSIONS The current study demonstrates the substantial prognostic power of MRPP over both APMHR and HRR% to predict CV events following an otherwise negative ESE for myocardial ischemia.
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Affiliation(s)
- Mark Whitman
- Cardiac Investigations Unit, Logan HospitalMeadowbrook, Yatala, Australia
- School of Human Movement and Nutrition Sciences, University of QueenslandBrisbane, Australia
| | - Carly Jenkins
- Cardiac Investigations Unit, Logan HospitalMeadowbrook, Yatala, Australia
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22
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Coutinho RQ, Montarroyos UR, Barros IMLD, Guimarães MJB, Leão APD, Costa LOBF, Medeiros AKDL, Monteiro MDF, Ferreira MDNL, Chalela WA, Pedrosa RP. Exercise Testing, Family History, and Subclinical Atherosclerosis Markers for Cardiovascular Risk Reclassification in Middle-Aged Women. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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23
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Hanson CA, Lu E, Ghumman SS, Ouellette ML, Löffler AI, Beller GA, Bourque JM. Long-term outcomes in patients with normal coronary arteries, nonobstructive, or obstructive coronary artery disease on invasive coronary angiography. Clin Cardiol 2021; 44:1286-1295. [PMID: 34216037 PMCID: PMC8428062 DOI: 10.1002/clc.23686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Normal or near normal coronary arteries (NNCA) or nonobstructive coronary artery disease (CAD) are commonly found on invasive coronary angiography (ICA). Hypothesis We aimed to determine long‐term outcomes by severity of CAD in a contemporary cohort of patients undergoing ICA for evaluation for ischemic heart disease. Methods We assessed a consecutive cohort of 925 patients who underwent non‐emergent ICA over 24 months. Cardiac death (CD), nonfatal myocardial infarction (NFMI), late revascularization, and medication use were assessed. Results Follow‐up data was available in 850 patients. Of patients without heart failure, at a median of 6.0 years, there was a significant decrease in survival free from CD or NFMI, and from all cardiac events, for those with obstructive CAD compared with patients with NNCAs or nonobstructive CAD (p < .001 for both). No differences between NNCA and nonobstructive CAD patients in rates of CD or NFMI (2.0% vs. 2.1%/year, p = .58) or all cardiac events (2.4% vs. 2.9%/year, p = .84) were observed. Conclusion Long‐term follow‐up in a contemporary cohort of consecutive patients undergoing non‐emergent ICA for detection of CAD showed no difference in annual rates of CD or NFMI, or total cardiac events, in patients with NNCAs versus those with nonobstructive CAD, whereas patients with obstructive CAD had significantly more events. Event rates were low and similar by gender. Use of aspirin, lipid lowering therapy, and beta‐blockers increased in all subgroups after ICA. We speculate this may explain the low incidence of subsequent cardiac events, and similar event rates in patients with NNCA and nonobstructive CAD, even in patients presenting with non‐ST‐elevation MI.
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Affiliation(s)
- Christopher A Hanson
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Edwin Lu
- Department of Medicine, University of North Carolina Health System, Chapel Hill, North Carolina, USA
| | - Saad S Ghumman
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michelle L Ouellette
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Adrián I Löffler
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - George A Beller
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jamieson M Bourque
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA.,Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
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Bays HE, Khera A, Blaha MJ, Budoff MJ, Toth PP. Ten things to know about ten imaging studies: A preventive cardiology perspective ("ASPC top ten imaging"). Am J Prev Cardiol 2021; 6:100176. [PMID: 34327499 PMCID: PMC8315431 DOI: 10.1016/j.ajpc.2021.100176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 02/07/2023] Open
Abstract
Knowing the patient's current cardiovascular disease (CVD) status, as well as the patient's current and future CVD risk, helps the clinician make more informed patient-centered management recommendations towards the goal of preventing future CVD events. Imaging tests that can assist the clinician with the diagnosis and prognosis of CVD include imaging studies of the heart and vascular system, as well as imaging studies of other body organs applicable to CVD risk. The American Society for Preventive Cardiology (ASPC) has published "Ten Things to Know About Ten Cardiovascular Disease Risk Factors." Similarly, this "ASPC Top Ten Imaging" summarizes ten things to know about ten imaging studies related to assessing CVD and CVD risk, listed in tabular form. The ten imaging studies herein include: (1) coronary artery calcium imaging (CAC), (2) coronary computed tomography angiography (CCTA), (3) cardiac ultrasound (echocardiography), (4) nuclear myocardial perfusion imaging (MPI), (5) cardiac magnetic resonance (CMR), (6) cardiac catheterization [with or without intravascular ultrasound (IVUS) or coronary optical coherence tomography (OCT)], (7) dual x-ray absorptiometry (DXA) body composition, (8) hepatic imaging [ultrasound of liver, vibration-controlled transient elastography (VCTE), CT, MRI proton density fat fraction (PDFF), magnetic resonance spectroscopy (MRS)], (9) peripheral artery / endothelial function imaging (e.g., carotid ultrasound, peripheral doppler imaging, ultrasound flow-mediated dilation, other tests of endothelial function and peripheral vascular imaging) and (10) images of other body organs applicable to preventive cardiology (brain, kidney, ovary). Many cardiologists perform cardiovascular-related imaging. Many non-cardiologists perform applicable non-cardiovascular imaging. Cardiologists and non-cardiologists alike may benefit from a working knowledge of imaging studies applicable to the diagnosis and prognosis of CVD and CVD risk - both important in preventive cardiology.
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Affiliation(s)
- Harold E. Bays
- Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, Louisville KY 40213 USA
| | - Amit Khera
- UT Southwestern Medical Center, Dallas, TX USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore MD USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance CA USA
| | - Peter P. Toth
- CGH Medical Cener, Sterling, IL 61081 USA
- Cicarrone center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD USA
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25
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Baheti A, Hanson CA, McArdle M, Lall SK, Beller GA, Bourque JM. Lead aVR predicts early revascularization but not long-term events in patients referred for stress electrocardiography. PLoS One 2021; 16:e0249779. [PMID: 33831085 PMCID: PMC8032194 DOI: 10.1371/journal.pone.0249779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Exercise stress electrocardiography (ExECG) is recommended as a first-line tool to assess ischemia, but standard ST-analysis has limited diagnostic accuracy. ST elevation in lead aVR has been associated with left main and LAD disease in the population undergoing coronary angiography but has not been studied in the general population undergoing stress testing for the initial evaluation of CAD without coronary angiography. We sought to determine the predictive value of lead aVR elevation for ischemia, early revascularization, and subsequent cardiac events in consecutive patients undergoing ExECG. METHODS AND RESULTS The study cohort included 641 subjects referred for ExECG who were dichotomized by presence or absence of aVR elevation ≥1mm and compared for prevalence and predictors of ischemia and a composite of cardiac death, nonfatal myocardial infarction, and late revascularization. The cohort had a median age of 57 and 57% were male. The prevalence of aVR elevation was 11.5%. The prevalence of significant ischemia on patients who received imaging was significantly higher with aVR elevation (14.3% vs 2.3%, p<0.001). Early revascularization occurred in 10.9% with vs 0.2% without aVR elevation, p<0.001. No subjects without aVR elevation or ST-depression underwent early revascularization. However, cardiac event rates were similar over a median 4.0 years of follow-up with and without aVR elevation (2.8% vs. 2.6%, p = 0.80). aVR elevation did not predict long-term cardiac events by Kaplan-Meier survival analysis (p = 0.94) or Cox proportional hazards modeling (p = 0.35). CONCLUSIONS aVR elevation during ExECG predicts ischemia on imaging and early revascularization but not long-term outcomes and could serve as a useful adjunct to standard ST-analysis and potentially reduce the need for concurrent imaging.
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Affiliation(s)
- Aparna Baheti
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Christopher A. Hanson
- Division of Cardiovascular Medicine, Department of Medicine, The Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, United States of America
| | - Michael McArdle
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Sumeet K. Lall
- University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - George A. Beller
- Division of Cardiovascular Medicine, Department of Medicine, The Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, United States of America
| | - Jamieson M. Bourque
- Division of Cardiovascular Medicine, Department of Medicine, The Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, United States of America
- * E-mail:
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Bays HE, Taub PR, Epstein E, Michos ED, Ferraro RA, Bailey AL, Kelli HM, Ferdinand KC, Echols MR, Weintraub H, Bostrom J, Johnson HM, Hoppe KK, Shapiro MD, German CA, Virani SS, Hussain A, Ballantyne CM, Agha AM, Toth PP. Ten things to know about ten cardiovascular disease risk factors. Am J Prev Cardiol 2021; 5:100149. [PMID: 34327491 PMCID: PMC8315386 DOI: 10.1016/j.ajpc.2021.100149] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 12/12/2022] Open
Abstract
Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The “American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update” is a summary document (updated yearly) regarding CVD risk factors. This “ASPC Top Ten CVD Risk Factors 2021 Update” summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the “ASPC Top Ten CVD Risk Factors 2021 Update” to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.
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Affiliation(s)
- Harold E. Bays
- Medical Director / President, Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY USA
- Corresponding author.
| | - Pam R. Taub
- University of California San Diego Health, San Diego, CA USA
| | | | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard A. Ferraro
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alison L. Bailey
- Chief, Cardiology, Centennial Heart at Parkridge, Chattanooga, TN USA
| | - Heval M. Kelli
- Northside Hospital Cardiovascular Institute, Lawrenceville, GA USA
| | - Keith C. Ferdinand
- Professor of Medicine, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA USA
| | - Melvin R. Echols
- Assistant Professor of Medicine, Department of Medicine, Cardiology Division, Morehouse School of Medicine, New Orleans, LA USA
| | - Howard Weintraub
- NYU Grossman School of Medicine, NYU Center for the Prevention of Cardiovascular Disease, New York, NY USA
| | - John Bostrom
- NYU Grossman School of Medicine, NYU Center for the Prevention of Cardiovascular Disease, New York, NY USA
| | - Heather M. Johnson
- Christine E. Lynn Women's Health & Wellness Institute, Boca Raton Regional Hospital/Baptist Health South Florida, Clinical Affiliate Associate Professor, Florida Atlantic University, Boca Raton, FL USA
| | - Kara K. Hoppe
- Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Michael D. Shapiro
- Center for Prevention of Cardiovascular Disease, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Charles A. German
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Salim S. Virani
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center and Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Aliza Hussain
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Christie M. Ballantyne
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX USA
| | - Ali M. Agha
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX USA
| | - Peter P. Toth
- CGH Medical Center, Sterling, IL USA
- Cicarrone center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Balfour PC, Gonzalez JA, Shaw PW, Caminero MP, Holland EM, Melson JW, Sobczak M, Izarnotegui V, Watson DD, Beller GA, Bourque JM. High-frequency QRS analysis to supplement ST evaluation in exercise stress electrocardiography: Incremental diagnostic accuracy and net reclassification. J Nucl Cardiol 2020; 27:2063-2075. [PMID: 30506155 PMCID: PMC6542725 DOI: 10.1007/s12350-018-01530-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Exercise stress electrocardiography (ECG) alone is underutilized in part due to poor diagnostic accuracy. High-frequency QRS analysis (HF-QRS) is a novel tool to supplement ST evaluation during stress ECG. We compared the diagnostic accuracy and net reclassification of HF-QRS analysis compared with ST evaluation for substantial myocardial ischemia by exercise SPECT myocardial perfusion imaging (MPI). METHODS AND RESULTS Exercise SPECT MPI was performed in 257 consecutive eligible patients (mean age 59 ± 12, 67% male). An ischemic HF-QRS pattern was defined as a ≥ 1 µV absolute reduction and a ≥ 50% relative reduction of the root-mean-square of the 150-250 Hz band signal in ≥ 3 leads. Left ventricular ischemia of ≥ 10% on SPECT MPI was the diagnostic standard for substantial myocardial ischemia. HF-QRS analysis demonstrated incremental diagnostic value to ST evaluation plus clinical risk factors (AUC 0.804 vs 0.749, P < .0001). A HF-QRS + ST -analysis strategy identified 92.3% of subjects with substantial ischemia and no abnormality in 59.9% of the cohort. No cardiac events occurred in patients without substantial ischemia identified by HF-QRS analysis. CONCLUSIONS In this prospective analysis, exercise stress ECG with HF-QRS analysis identified any and substantial ischemia with high diagnostic accuracy and may allow more than half of referred patients to safely avoid imaging.
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Affiliation(s)
- Pelbreton C Balfour
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA
| | - Jorge A Gonzalez
- Division of Cardiovascular Disease, Scripps Clinic, La Jolla, CA, USA
| | | | | | | | - Jack W Melson
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA
| | - Michael Sobczak
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA
| | - Valerie Izarnotegui
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA
| | - Denny D Watson
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA
- Departments of Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | - George A Beller
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA
- Departments of Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamieson M Bourque
- Cardiovascular Division, Department of Medicine, Cardiovascular Imaging Center, University of Virginia Health System, 1215 Lee Street, Box 800662, Charlottesville, VA, 22908, USA.
- Departments of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
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Murthy VL, Nasir K. Staged testing as a solution to the challenges of testing lower risk patients. J Nucl Cardiol 2020; 27:1497-1500. [PMID: 30225816 PMCID: PMC6421111 DOI: 10.1007/s12350-018-1437-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA.
| | - Khurram Nasir
- Division of Cardiovascular Medicine, Center for Outcomes & Research Evaluation (CORE), Yale University School of Medicine & Yale New Haven Health, New Haven, CT, USA
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Smith L, Myc L, Watson D, Beller GA, Bourque JM. A high exercise workload of ≥ 10 METS predicts a low risk of significant ischemia and cardiac events in older adults. J Nucl Cardiol 2020; 27:1486-1496. [PMID: 30051345 PMCID: PMC6348049 DOI: 10.1007/s12350-018-1376-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients who achieve ≥ 10 METS during exercise SPECT myocardial perfusion imaging (MPI) have very low rates of significant ischemia and major adverse cardiac events (MACE). It is unknown how many older adults can achieve ≥ 10 METS, and if low risk extends to this subgroup. METHODS AND RESULTS We examined the workload achieved, prevalence and predictors of ischemia, and MACE (cardiac death, non-fatal MI, late revascularization) in a cohort of 382 patients ≥ 65 years of age who underwent exercise 99mTc SPECT MPI. The cohort was 64.4% male and 36.9% had known coronary artery disease (CAD). All achieved ≥ 85% of maximum age-predicted heart rate. A workload of ≥ 10 METS was achieved in 25.4%; 50.3% attained 7-9 METS, and 24.4% reached < 7 METS. There was a stepwise decrease in prevalence of any ischemia and significant ischemia (≥ 10% of the left ventricle (LV)) as workload increased (P = 0.037). Patients achieving ≥ 10 METS had a 3.1% prevalence of ≥ 10% LV ischemia (1.2% in those without ST depression). Cardiac death and MACE rates in the ≥ 10 METS subgroup were 0.6%/year and 2.6%/year over a median 7.0 years of follow-up. CONCLUSIONS A substantial proportion of older adults who undergo exercise SPECT MPI can achieve ≥ 10 METS. This subgroup has low rates of significant LV ischemia and MACE. The favorable diagnostic and prognostic implications of achieving a high workload in an older adult population suggest it is feasible, with certain exceptions, to include this subgroup in workload-based strategies of provisional imaging.
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Affiliation(s)
- LaVone Smith
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Lukasz Myc
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Denny Watson
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | - George A Beller
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Jamieson M Bourque
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
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Liti B, Krainski F, Gabriel A, Hiendlmeyr B, Manola A, Perucki W, Pershwitz G, Kumar A, Duvall WL. Clinical effectiveness of an outpatient pathway for low-risk chest pain emergency department visits. J Nucl Cardiol 2020; 27:1341-1348. [PMID: 31321618 DOI: 10.1007/s12350-019-01814-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 06/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies suggest that patients who present with atypical chest pain and are low or low-intermediate risk can safely undergo a rapid rule-out for cardiac ischemia with serial ECGs and cardiac biomarkers followed by additional testing as needed. We sought to evaluate a novel Emergency Department (ED) protocol for patients to undergo their additional functional testing as an outpatient. METHODS Patients presenting to the ED with atypical chest pain, normal ECG, and negative cardiac troponin felt to be low risk were referred for outpatient stress testing within 72 hours of presentation as part of a pilot program. We analyzed test characteristics, length of stay, and 30-day return visits to ED in the pilot group and compared results to a similar cohort assessed in the ED by a traditional chest pain observation protocol. RESULTS A total of 156 patients were included over a 5-month period with 29.5% not returning for testing. There was a 70% reduction in length of stay for outpatient stress test protocol patients. All-cause and cardiac return visits to the ED were not significantly different between the outpatient cohort and the traditional chest pain unit group and were reduced by 47 and 75%, respectively, in patients who completed their outpatient testing. The provisional injection protocol resulted in a 81% reduction in radiation exposure when compared to traditional MPI stress protocols due to a greater utilization of exercise treadmill tests without imaging. CONCLUSION Outpatient stress testing is a reliable alternative to traditional chest pain observation with a significantly shorter length of stay, reduced healthcare costs, and improved radiation safety profile for patients when compared to traditional inpatient observation.
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Affiliation(s)
- Besiana Liti
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Felix Krainski
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Andre Gabriel
- Department of Medicine, University of Connecticut Medical Center, Farmington, CT, USA
| | - Brett Hiendlmeyr
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Akrivi Manola
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - William Perucki
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Gene Pershwitz
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Ajay Kumar
- Department of Medicine, Hartford Hospital, Hartford, CT, USA
| | - W Lane Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
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Sex-differences in aortic stenosis: Effect on functional capacity and prognosis. Int J Cardiol 2019; 304:130-134. [PMID: 31813683 DOI: 10.1016/j.ijcard.2019.11.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/05/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The patterns of left ventricular (LV) remodeling in aortic stenosis (AS) are different in men and women. We aimed to assess whether there were also sex differences in measurements obtained on exercise testing. METHODS Echocardiography and ETT (modified Bruce) were performed at presentation in 316 patients with moderate or severe AS. An early rapid rise in heart rate (RR-HR) during ETT was defined as achieving at least 85% of target heart rate or ≥50% increase from baseline within the first 6 min. RESULTS Mean age was 66 ± 12 years in men (n = 212) and 65 ± 12 years in women (n = 104) (p = NS). Men walked longer than women on the treadmill (10.4 ± 4.3 vs. 8.2 ± 4.2 min, p < 0.001) and achieved higher METs (9.2 ± 4.5 vs. 7.6 ± 4.3, p < 0.001), but both sexes achieved similar levels of peak heart rate and blood pressure. During a mean follow up of 34.9 ± 34.6 months, 29 deaths occurred (20 in men and 9 in women, p = 0.821). Age and body mass index were strong determinants of lower METs in men, but not in women, while Zva was a determinant in women but not in men. RR-HR was a strong determinant of lower METs in both sexes. Event-free survival was significantly lower in men with RR-HR but not in women. CONCLUSION Exercise capacity was lower in women than men, and the determinants of exercise capacity differed. An RR-HR was a strong determinant of lower METs in both sexes, but predicted all-cause mortality only in men.
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Beri N, Dang P, Bhat A, Venugopal S, Amsterdam EA. Usefulness of Excellent Functional Capacity in Men and Women With Ischemic Exercise Electrocardiography to Predict a Negative Stress Imaging Test and Very Low Late Mortality. Am J Cardiol 2019; 124:661-665. [PMID: 31300200 DOI: 10.1016/j.amjcard.2019.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
Exercise electrocardiography (ExECG) is widely employed to assess patients for coronary artery disease but it has limited diagnostic accuracy. Many patients with positive (ischemic) tests based on exercise-induced ST depression undergo secondary evaluation by noninvasive stress imaging. We hypothesized that high functional capacity in patients with positive ExECG could predict: (1) negative results in secondary evaluation by exercise echocardiography (ESE) or myocardial perfusion scintigraphy (MPS) and (2) low mortality on late follow-up. We evaluated 511 consecutive patients (312 men, 199 women; age 51 ± 9 years) referred for ESE or MPS after an ischemic ExECG at a treadmill workload of ≥10 metabolic equivalents. All-cause mortality was also obtained. Of 511 patients, 401 underwent ESE and 110 had MPS for secondary study. ESE was negative in 94% (376 of 401) and positive in 6% (25 of 401). MPS was also negative in 94% (103 of 110) and positive in 6% (7 of 110). Total stress imaging results were negative in 92% (286 of 312) of men and 97% (193 of 199) of women. During follow-up of approximately 6 years, there were 3 deaths with total all-cause mortality of 0.6% and average annual mortality of 0.1%. In conclusion, high functional capacity in patients with an ischemic ExECG predicts a negative ESE or MPS in a large majority of patients and very favorable late survival in both men and women. These results suggest that patients with ischemic ExECGs and a workload of ≥10 metabolic equivalents during ExECG may not require additional noninvasive or invasive evaluation.
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Hanson CA, Bourque JM. Functional and Anatomical Imaging in Patients with Ischemic Symptoms and Known Coronary Artery Disease. Curr Cardiol Rep 2019; 21:79. [PMID: 31264115 DOI: 10.1007/s11886-019-1155-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW This review is aimed at summarizing recent advances in functional, anatomical, and hybrid imaging techniques used in the assessment of ischemic complaints in patients with known coronary artery disease (CAD). RECENT FINDINGS Cardiovascular imaging has seen significant growth over the last decade in the fields of coronary computed tomography angiography (CCTA), FFR derived from CCTA, cardiac magnetic resonance, radionuclide myocardial perfusion imaging, and hybrid imaging for the purposes of evaluating symptoms concerning for ischemia. This growth stems from refinement of imaging techniques and hardware and software advances that have made current techniques more accurate with less acquisition time. However, every anatomic and functional imaging modality has important technical and patient-specific limitations. This review assesses these issues, guides a patient-centered imaging approach, and identifies important research questions to resolve. Recent advances in non-invasive cardiovascular imaging can provide important information in patients with known CAD beyond traditional imaging techniques; the use of these novel tools refines the clinical management of complex patients with ischemic symptoms and known CAD.
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Affiliation(s)
- Christopher A Hanson
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Box 800158, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Box 800158, 1215 Lee Street, Charlottesville, VA, 22908, USA. .,Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
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Diagnostic Yield of Customized Exercise Provocation Following Routine Testing. Am J Cardiol 2019; 123:2044-2050. [PMID: 30982540 DOI: 10.1016/j.amjcard.2019.03.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/03/2019] [Accepted: 03/07/2019] [Indexed: 11/20/2022]
Abstract
Clinical guidelines advocate for customization of exercise testing to address patient-specific diagnostic goals, including reproduction of presenting exertional symptoms. However, the diagnostic yield of adding customized exercise testing to graded exercise in patients presenting with exertional complaints has not been rigorously examined and is the focus of this study. Using prospectively collected data, we analyzed the diagnostic yield of customized additional exercise provocation following inconclusive graded exercise test with measurement of gas exchange. Additional testing was defined as "positive" if it revealed a clinically-actionable diagnosis related to the chief complaint or reproduced symptoms in the absence of an explanatory diagnosis or pathology. Of 1,110 patients who completed a graded test, 122 (11%) symptomatic patients underwent additional customized exercise testing (e.g., sprint intervals and race simulations). Compared with those who did not undergo additional testing, this group was younger (29 [interquartile range 19 to 45] vs 46 [25 to 58] year old) and disproportionately female (43% vs 27%). Presenting symptoms included palpitations (46%), lightheadedness/syncope (25%), chest pain (14%), dyspnea (11%), and exertional intolerance (3%). Additional testing was "positive" in 48 of 122 (39%) of patients by revealing a clinically actionable diagnosis in 26 of 48 (54%) or reproducing symptoms without an explanatory diagnosis in 22 of 48 (46%). In conclusion, while patient-centered customization of exercise testing is suggested by clinical guidelines, these data are the first to demonstrate that the selective addition of customized exercise provocation following inconclusive graded exercise testing improves the diagnostic yield of exercise assessment.
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Xian Quah J, Greaves K, Thomas L, Stanton T. The Clinical Utility and Enduring Versatility of Stress Echocardiography. Heart Lung Circ 2019; 28:1376-1383. [PMID: 31078426 DOI: 10.1016/j.hlc.2019.02.188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/08/2019] [Accepted: 02/01/2019] [Indexed: 01/06/2023]
Abstract
Stress echocardiography is an established cardiac imaging modality for the detection and quantification of severity of coronary artery disease. In recent years, there has also been an increasing use of stress echocardiography in the assessment of non-ischaemic cardiac disease given its ability to assess functional capacity and haemodynamic changes with exercise which can help guide therapy and inform prognosis. The emerging use of strain, myocardial contrast and three-dimensional (3D) echocardiography further assists in improving diagnostic accuracy particularly in patients with coronary artery disease. This paper summarises the protocols, indications and clinical applications of stress echocardiography in both ischaemic and non-ischaemic cardiac disease.
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Affiliation(s)
- Jing Xian Quah
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia; University of the Sunshine Coast, Brisbane, Qld, Australia
| | - Liza Thomas
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tony Stanton
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia; University of the Sunshine Coast, Brisbane, Qld, Australia; School of Medicine, Griffith University, Sunshine Coast University Hospital, Brisbane, Qld, Australia.
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Jaafar Z, Mokhtar AH, Abdul Hamid MS, Mohamed Ali MR. The comparison of the exercise stress test tolerance using Bruce and Balke-Ware protocols in Malaysians. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.18.03865-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sirico F, Fernando F, Di Paolo F, Adami PE, Signorello MG, Sannino G, Bianco A, Cerrone A, Baioccato V, Filippi N, Ferrari U, Tuzi M, Nurzynska D, Di Meglio F, Castaldo C, D'Ascenzi F, Montagnani S, Biffi A. Exercise stress test in apparently healthy individuals - where to place the finish line? The Ferrari corporate wellness programme experience. Eur J Prev Cardiol 2019; 26:731-738. [PMID: 30674206 DOI: 10.1177/2047487318825174] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS The aim of our study was to assess the clinical significance of the exercise stress testing endpoints, namely 85% of maximal theoretical heart rate (MTHR), metabolic equivalent of task, and rating of perceived exertion (RPE), and their relation to electrocardiographic (ECG) changes in a healthy adult population. METHODS A cross-sectional study was conducted on 408 males and 52 females (mean age 39.4 ± 8.6 years) who performed the maximal cycle ergometer exercise stress test until volitional exhaustion, reporting the RPE score at 85% of MTHR and at peak exercise. Metabolic equivalents of task were indirectly calculated from the maximum workload and compared with the predicted values. Sitting torso-lead ECG and blood pressure were recorded at rest, during exercise and during recovery. RESULTS Of 460 participants, 73% exceeded 85% of MTHR. The RPE score represented the overall most significant endpoint of exercise stress testing, with the median value of 17 at peak exercise. ECG events were detected in 23/124 (18.5%) who reached ≤ 85% of MTHR and in 61/336 (18.2%) who achieved >85% of MTHR ( p = 0.92). In the latter group, 54% of ECG changes occurred at < 85% of MTHR and 46% at > 85% of MTHR ( p = 0.51). If the exercise stress testing had been interrupted at ≤ 85% of MTHR, almost half of the ECG events would have remained undetected and 35% of the cardiovascular abnormalities observed at the diagnostic follow-up would have remained undiagnosed. CONCLUSION Terminating exercise stress testing before volitional exhaustion and an RPE score of 17 limits the test accuracy and reduces the possibility to detect cardiovascular abnormalities in apparently healthy adult populations.
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Affiliation(s)
- Felice Sirico
- 1 Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy.,2 University of Naples Federico II, Department of Public Health, Italy
| | - Fredrick Fernando
- 1 Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
| | - Fernando Di Paolo
- 1 Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
| | - Paolo Emilio Adami
- 1 Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
| | | | - Giuseppe Sannino
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Antonio Bianco
- 2 University of Naples Federico II, Department of Public Health, Italy
| | | | | | - Nicola Filippi
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Umberto Ferrari
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Manuel Tuzi
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Daria Nurzynska
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Franca Di Meglio
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Clotilde Castaldo
- 2 University of Naples Federico II, Department of Public Health, Italy
| | - Flavio D'Ascenzi
- 1 Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
| | | | - Alessandro Biffi
- 1 Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
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Whitman M, Sabapathy S, Jenkins C, Adams L. Is downstream cardiac testing required in patients with reduced functional capacity and otherwise negative exercise stress test? A single center observational study. Cardiol J 2018; 26:753-760. [PMID: 30234905 DOI: 10.5603/cj.a2018.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 07/05/2018] [Accepted: 07/07/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Exercise stress testing (EST) in patients with poor functional capacity measured by time on treadmill is typically deemed inconclusive and usually leads to further downstream testing. The aim of this study was firstly to evaluate the maximum rate pressure product (MRPP) during initial EST to assessthe need for follow-up testing; and secondly to investigate if MRPP is better than age predicted maximum heart rate (APMHR) for diagnostic outcome based on follow up cardiovascular (CV) events in patients with inconclusive EST due to poor functional capacity. METHODS From a total of 2761 tests performed, 236 tests were considered inconclusive due to poor functional capacity which were available for analysis. From receiver operating characteristic (ROC) analysis, a cut-off value for MRPP of 25000 was chosen using CV events as the outcome measure (sensitivity 97%, specificity 45%). Cases were then categorised into those with an MRPP > 25000 and < 25000. RESULTS Regardless of treadmill time, any patient attaining an MRPP > 25000 had no abnormal downstream testing or CV events at 2 years follow-up. On ROC analysis MRPP outperformed APMHR for sensitivity and specificity (area under curve 0.76 vs. 0.59, respectively). CONCLUSIONS The results suggest that regardless of functional capacity, individuals whose EST is terminated at maximal fatigue, with no electrocardiogram evidence or symptoms of myocardial ischemia and yields an MRPP > 25000, do not require further downstream testing. Furthermore, this group of patients, while not immune to future CV events, have significantly better outcomes than those not attaining a MRPP > 25000.
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Affiliation(s)
- Mark Whitman
- Griffith University, Gold Coast, 4215 Southport, Australia. .,QLD Health, Logan Hospital, 4131 Meadowbrook, Australia.
| | | | - Carly Jenkins
- QLD Health, Logan Hospital, 4131 Meadowbrook, Australia
| | - Lewis Adams
- Griffith University, Gold Coast, 4215 Southport, Australia
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Ouellette ML, Löffler AI, Beller GA, Workman VK, Holland E, Bourque JM. Clinical Characteristics, Sex Differences, and Outcomes in Patients With Normal or Near-Normal Coronary Arteries, Non-Obstructive or Obstructive Coronary Artery Disease. J Am Heart Assoc 2018; 7:JAHA.117.007965. [PMID: 29720503 PMCID: PMC6015317 DOI: 10.1161/jaha.117.007965] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Normal or near‐normal coronary arteries (NNCAs) or nonobstructive coronary artery disease (CAD) are found on invasive coronary angiography in ≈55% of patients. Some attribute this to frequent referral of low‐risk patients. We sought to identify the referral indications, pretest risk, key clinical characteristics, sex, and outcomes in patients with NNCAs and nonobstructive CAD versus obstructive CAD on nonemergent invasive coronary angiography. Methods and Results Over 24 months, 925 consecutive patients were classified as having NNCAs (≤20% stenosis), nonobstructive CAD (21–49% stenosis), or obstructive CAD (≥50% stenosis). Outcomes included cardiac death, nonfatal myocardial infarction, and late revasclarization. NNCAs were found in 285 patients (31.0%), nonobstructive CAD in 125 (13.5%), and obstructive CAD in 513 (55.5%). NNCAs or nonobstructive CAD was found in 40.5% with stress ischemia, 27.9% after a non‐ST‐elevation myocardial infarction, and in 55.5% with stable or unstable angina. More women than men (53.5% versus 37.2%; P<0.001) had NNCAs or nonobstructive CAD across all referral indications. Pretest risk was high and ICA appropriate in 75.5% and 99.2% of patients, respectively. Annual rates of cardiac death or nonfatal myocardial infarction were 1.0%, 1.1%, and 6.7%, respectively, for patients with NNCAs, nonobstructive CAD, and obstructive CAD (P<0.001). No sex differences in outcomes were observed with either NNCAs, nonobstructive CAD, or obstructive CAD (P=0.84). Conclusions Many (44.5%) patients undergoing nonemergent invasive coronary angiography have NNCAs or nonobstructive CAD despite high pretest risk, including ischemia and troponin elevation. Although women had more NNCAs or nonobstructive CAD, there were no differences in event rates by sex. Patients with NNCAs and nonobstructive CAD had very low event rates.
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Affiliation(s)
- Michelle L Ouellette
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Adrián I Löffler
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - George A Beller
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Virginia K Workman
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Eric Holland
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA
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Ho JS, Cannaday JJ, FitzGerald SJ, Leonard D, Finley CE, Wade WA, Reinhardt DB, Ellis JR, Barlow CE, Haskell WL, Defina LF, Gibbons LW, Cooper KH. Relation of Coronary Artery Diameters With Cardiorespiratory Fitness. Am J Cardiol 2018; 121:1065-1071. [PMID: 29502792 DOI: 10.1016/j.amjcard.2018.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/04/2018] [Accepted: 01/08/2018] [Indexed: 12/14/2022]
Abstract
Cardiorespiratory fitness is associated with reduced cardiovascular morbidity and mortality when adjusted for traditional risk factors. Mechanisms by which fitness reduces risk have been studied but remain incompletely understood. We hypothesize that higher fitness is associated with larger coronary artery diameters independent of its effect on traditional risk factors. Two independent measurements of the proximal diameters of the left main, left anterior descending, left circumflex, and right coronary arteries were obtained from gated multidetector computed tomography scans in 500 men from the Cooper Center Longitudinal Study (CCLS). Men with coronary artery calcium scores ≥10 were excluded. Fitness was measured with a maximal exercise treadmill test and reported by quintiles and as a function of METs. We then evaluated the relation between coronary artery diameters and fitness using mixed effect regression models. Higher fitness was associated with larger coronary artery diameters after adjustment for body surface area, smoking status, low-density lipoprotein and high-density lipoprotein cholesterol, resting systolic blood pressure, and serum glucose. When examined continuously, each MET increase in fitness was associated with a mean 0.03 ± 0.01 mm larger diameter of the left main, a 0.04 ± 0.01 mm larger diameter of the left anterior descending, a 0.05 ± 0.01 mm larger diameter of the left circumflex, and a 0.07 ± 0.01 mm larger diameter of the right coronary artery (p = 0.002). This correlation between fitness and coronary artery diameters was most prominent for fitness levels above 10 METs. In conclusion, higher fitness is associated with larger coronary artery diameters.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - William L Haskell
- Stanford Prevention Research Center, Stanford University, Stanford, California
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Löffler AI, Perez MV, Nketiah EO, Bourque JM, Keeley EC. Usefulness of Achieving ≥10 METs With a Negative Stress Electrocardiogram to Screen for High-Risk Obstructive Coronary Artery Disease in Patients Referred for Coronary Angiography After Exercise Stress Testing. Am J Cardiol 2018; 121:289-293. [PMID: 29191566 DOI: 10.1016/j.amjcard.2017.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 02/03/2023]
Abstract
Functional capacity in exercise stress testing is an independent predictor of cardiac events. Routine use of nuclear perfusion imaging increases radiation burden and cost. Our goal was to assess the clinical utility of exercise functional capacity with stress electrocardiogram (ECG) as an adjunct in predicting the presence of high-risk obstructive coronary artery disease (CAD) on diagnostic coronary angiography. We performed a retrospective study of patients who underwent exercise stress testing for the evaluation of chest pain and underwent diagnostic coronary angiography within the subsequent 3 months. High-risk CAD was defined as coronary artery diameter stenosis of ≥70% in the proximal left anterior descending artery, ≥70% diameter stenosis in 3 major epicardial arteries, or ≥50% diameter stenosis in the left main artery. Univariable and multivariable analyses were performed to identify predictors of high-risk CAD. Of the 412 patients, 105 (25%) had high-risk CAD on coronary angiography. On multivariate logistic regression, we found that positive stress ECG, abnormal stress imaging, left ventricular ejection fraction, and male gender were independent predictors of high-risk CAD. The strongest predictor was positive stress ECG (hazard ratio 3.16, 95% confidence interval 1.90 to 5.27, p <0.001). Functional capacity measures alone were not independent predictors of high-risk CAD. Achieving ≥10 METs with a negative stress ECG resulted in 94% sensitivity and 97% negative predictive value in identifying high-risk CAD. This supports the strategy for provisional use of myocardial perfusion imaging in patients with low functional capacity and/or abnormal stress ECG to minimize cost and radiation exposure.
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Affiliation(s)
- Adrián I Löffler
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Margarita V Perez
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Emmanuel O Nketiah
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Jamieson M Bourque
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Ellen C Keeley
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Cardiology, University of Virginia, Charlottesville, Virginia.
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Barbieri A, Mantovani F, Bursi F, Bartolacelli Y, Manicardi M, Lauria MG, Boriani G. 12-year Temporal Trend in Referral Pattern and Test Results of Stress Echocardiography in a Tertiary Care Referral Center with Moderate Volume Activities and Cath-lab Facility. J Cardiovasc Echogr 2018; 28:32-38. [PMID: 29629257 PMCID: PMC5875133 DOI: 10.4103/jcecho.jcecho_48_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Data on stress echocardiography (SE) time-related changes in referral patterns and diagnostic yield for detection of inducible ischemia could enhance Echo Lab quality benchmarks and performance measures. Aim This study aims to evaluate temporal trends in SE test results among ambulatory patients with suspected or known coronary artery disease (CAD) in a tertiary care referral center with moderate (>100/year) volume SE activities and Cath-Lab facility. Methods From January 2004 to December 2015, 1954 patients (mean age 62 ± 12 years, 42% women, 27% with known CAD) underwent SE (1673 exercise SE, 86%, 246 pharmacological SE, 12%, 35 pacing SE, 2%). Time was grouped into three 4 year periods, where clinical data and test results were evaluated. Results Our series comprised low-to-intermediate pretest probability of CAD throughout the observation period (overall pretest probability of CAD 19% ± 15%). A progressive decline over time in the rate of pharmacological SE instead of a dramatic increment of exercise SE (79%-96%, P < 0.0001) was noted. The use of beta-blockers increased (from 43% to 66%, P < 0.0001), while the use of nitrates decreased (from 11% to 4%, P < 0.0001) over time. We noted a very uncommon occurrence of abnormal test results with a further decrease in the last period (from 11% to 3%, P < 0.0001). Conclusions We observed, over a 12-year period, a progressive decrease in the frequency of inducible myocardial ischemia among patients with known or suspected CADe referred to our Echo Lab for SE with Cath-Lab facility, and this trend was parallel to changes in SE referral practice. These findings are particularly relevant if we consider the practical implications on diagnostic SE accuracy and risk assessment.
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Affiliation(s)
- Andrea Barbieri
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Mantovani
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Bursi
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Ylenia Bartolacelli
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Manicardi
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Giulia Lauria
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Boriani
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Mordi IR, Badar AA, Irving RJ, Weir-McCall JR, Houston JG, Lang CC. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag 2017; 13:427-437. [PMID: 29200864 PMCID: PMC5701553 DOI: 10.2147/vhrm.s106838] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The aim of this review was to discuss the current literature regarding the utility of noninvasive imaging in diagnosis and management of stable coronary artery disease (CAD) including recent data from large randomized trials assessing diagnosis and prognosis. Current guidelines recommend revascularization in patients with refractory angina and in those with potential prognostic benefit. Appropriate risk stratification through noninvasive assessment is important in ensuring patients are not exposed to unnecessary invasive coronary angiograms. The past 20 years have seen an unprecedented expansion in noninvasive imaging modalities for the assessment of stable CAD, with cardiovascular magnetic resonance and computed tomography complementing established techniques such as myocardial perfusion imaging, echocardiography and exercise electrocardiogram. In this review, we examine the current state-of-the-art in noninvasive imaging to provide an up-to-date analysis of current investigation and management options.
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Affiliation(s)
- Ify R Mordi
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.,Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
| | - Athar A Badar
- Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
| | - R John Irving
- Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
| | | | - J Graeme Houston
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.,Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
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Prognostic Usefulness of Cardiac Stress Test Modalities in Patients With Type 2 Diabetes Mellitus Who Underwent Myocardial Perfusion Scintigraphy (from the Basel Asymptomatic High-Risk Diabetics' Outcome Trial). Am J Cardiol 2017; 120:1098-1103. [PMID: 28807404 DOI: 10.1016/j.amjcard.2017.06.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/10/2017] [Accepted: 06/28/2017] [Indexed: 12/21/2022]
Abstract
Our study aimed to assess predictors of the stress test technique used and to evaluate the impact of exercise level achieved on risk stratification in patients with asymptomatic type 2 diabetes without a previous coronary artery disease. Little is known whether co-morbidities of these patients predict the stress technique and whether physical performance provides risk stratification: 400 patients underwent clinical evaluation and myocardial perfusion scintigraphy (MPS) using physical or pharmacological stress. Physical patients were divided into 2 groups: achieving <6 and ≥6 METs, respectively. The mean follow-up time was 2 years. Major cardiac events (MACEs) included myocardial infarction and/or cardiac death. Independent predictors of pharmacological stress were a body mass index of >30 kg/m2 (hazard ratio 1.076, 95% confidence interval 1.027 to 1.127, p = 0.002) and a peripheral arterial disease (hazard ratio 2.888, 95% confidence interval 1.446 to 5.769, p = 0.003). Pharmacological patients had more MACE than physical patients (3.2% vs 1.0%, p = 0.03). Patients achieving <6 METs had a similar MACE rate as pharmacological patients (3.0% vs 3.2%, p = not significant) and more MACE than patients achieving ≥6 METs (3.0% vs 0.4%, p = 0.01). In patients achieving <6 METs and in pharmacological patients, MPS added an incremental prognostic value to pretest information (p values for global chi-square 0.012 and 0.04, respectively). In high-risk asymptomatic diabetic patients, co-morbidities were predictive of the stress technique used. Pharmacological patients had more MACE, similar to those unable to achieve 6 METs. MPS provided an incremental prognostic value in pharmacological patients and in patients with <6METs. In contrast, patients who were able to achieve ≥6 METs were at low risk and do not need further risk stratification.
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Vaidya GN. Application of exercise ECG stress test in the current high cost modern-era healthcare system. Indian Heart J 2017; 69:551-555. [PMID: 28822530 PMCID: PMC5560878 DOI: 10.1016/j.ihj.2017.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/24/2017] [Accepted: 06/14/2017] [Indexed: 12/15/2022] Open
Abstract
Exercise electrocardiogram (ECG) tests boasts of being more widely available, less resource intensive, lower cost and absence of radiation. In the presence of a normal baseline ECG, an exercise ECG test is able to generate a reliable and reproducible result almost comparable to Technitium–99 m sestamibi perfusion imaging. Exercise ECG changes when combined with other clinical parameters obtained during the test has the potential to allow effective redistribution of scarce resources by excluding low risk patients with significant accuracy. As we look towards a future of rising healthcare costs, increased prevalence of cardiovascular disease and the need for proper allocation of limited resources; exercise ECG test offers low cost, vital and reliable disease interpretation. This article highlights the physiology of the exercise ECG test, patient selection, effective interpretation, describe previously reported scores and their clinical application in today’s clinical practice.
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Froelicher V. Should the exercise test be reimbursed as the hangman or the baker? Int J Cardiol 2017; 236:123-124. [DOI: 10.1016/j.ijcard.2017.01.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gonzalez JA, Beller GA. Choosing exercise or pharmacologic stress imaging, or exercise ECG testing alone: How to decide. J Nucl Cardiol 2017; 24:555-557. [PMID: 26846366 DOI: 10.1007/s12350-016-0409-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Gimelli A, Liga R, Pasanisi EM, Casagranda M, Coceani M, Marzullo P. Influence of cardiac stress protocol on myocardial perfusion imaging accuracy: The role of exercise level on the evaluation of ischemic burden. J Nucl Cardiol 2016; 23:1114-1122. [PMID: 25814218 DOI: 10.1007/s12350-015-0101-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 02/16/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Some specifics of cardiac stress protocols, i.e., stressor used or exercise level achieved, may impact myocardial perfusion imaging (MPI) accuracy. METHODS Four-hundred and seventy-five patients were submitted to MPI and coronary angiography. MPI was performed after exercise (303 patients) or dipyridamole stress (172 patients). A coronary stenosis ≥70% was considered significant. In case of exercise test, a peak heart rate (HR) <85% of the maximal age predicted was considered submaximal and categorized as follows: >75% and <85% ("Group 1"); <75% ("Group 2"). RESULTS At coronary angiography, 312/475 (66%) patients showed significant stenosis. In the overall population, MPI showed a high accuracy in unmasking significant coronary stenosis, independently of the stress protocol adopted (AUC .76 for exercise vs .78 for vasodilator; P = NS). However, in case of an exercise stress test, a significant interaction between peak %HR and MPI diagnostic power was evident. While an elevated accuracy was still maintained in "Group 1" patients (AUC .79; P vs maximal exercise = NS), a significant drop was demonstrated in "Group 2" patients (AUC .66; P vs maximal exercise = .012, and P vs "Group 1" = .042). CONCLUSIONS The accuracy of MPI is not influenced by the stress protocol adopted. Exercise MPI maintains an elevated accuracy as long as the %HR remains >75%.
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Affiliation(s)
- Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
| | - Riccardo Liga
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy.
| | | | - Mirta Casagranda
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
| | - Michele Coceani
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
| | - Paolo Marzullo
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
- CNR, Institute of Clinical Physiology, Pisa, Italy
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Spadafora M, Salvatore M, Cuocolo A. Stress protocol and accuracy of myocardial perfusion imaging: Is it better to start from the end? J Nucl Cardiol 2016; 23:1123-1127. [PMID: 25824021 DOI: 10.1007/s12350-015-0119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Marco Spadafora
- Nuclear Medicine Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | | | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy.
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Bourque JM, Beller GA. Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies. JACC Cardiovasc Imaging 2016; 8:1309-21. [PMID: 26563861 DOI: 10.1016/j.jcmg.2015.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/15/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023]
Abstract
Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Department of Radiology, University of Virginia Health System, Charlottesville, Virginia.
| | - George A Beller
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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